Saturday, March 6, 2010

"Flaming Lisa" gave a dissenting opinion on my post about death, "Checking out". While I disagree with her, I do believe in fairness. I'm therefore putting up her entire comment verbatim, as an opposing viewpoint.

Hmmmm. It's too bad that the original post had to be all balled up with Killer Kevorkian and Terri Schiavo (2 very different cases).

As a Catholic, food and water are considered ordinary (required) care even if medically assisted--so Terri Schiavo would be alive and her murder would never have happened and perhaps her parents would have been able to care for her as they wished. Wow! How awful is that????

Kevorkian is a murderer and has served jail time for such a crime.

This woman in the original post, however, was trying to die but was subject to her husband's wishes. As much as you "healthcare workers" keep harping that this happens all the time, I have a hard time believing it. I don't see hospitals crammed with people being given every possible test under the sun in these circumstances. It is an exaggeration on your part.

MDKauffman: is it really so hard to administer antibiotics to a woman with a UTI? Where's your compassion you idiot? UTI's don't have to be a dying persons disease--you just don't like old people. Get a new profession.

You've all lost your heart! How cold and hard have you gotten???? I am convinced now that NO ONE should be making these decisions (and especially not you people) for a family except the family. Thank you for clearing that up for me and making me thoroughly distrust the medical establishment.

78 comments:

Wow. Wow. I think maybe Lisa ought to spend some time in an acute care setting - see the cost of the care that is being provided - I mean dollars and cents as well as emotional for both the family and the caretakers. And see how torturous some of the care can be to a body that is so wasted and so ready for rest...I am glad that in all fairness you posted this ...I find it hard to believe that she could read all the testimonials and still come across this harsh. I pray that she is never in the same position as all those families were. I would write more but I need to get to work - and work in that setting that she no longer has any type of faith in...only my job is that of healing newborns - the beginning not the ending of life most of the time, but her condemnation was all inclusive.

I get the feeling that maybe Lisa had to deal with this issue in her family and is still upset about it. I don't think any of our comments on the original post were heartless or cold. The majority of us healthcare workers mourn right along with the families when tragedy strikes.

I don't think really anyone has any grasp of this type of situation unless you've been there. Unless it is your mother, wife, husband, father, son, etc., you can only look from the outside in and make judgement calls.

Medical personnel excluded.

Seriously.

There is never a blanket situation, each one is entirely unique.

I hope Lisa is never in a situation that challenges her feelings versus her faith. I always said regarding my mother's life in a vegetative coma that we were the ones keeping her here for over 3 years through "medical" means. God wanted her on the day of her stroke.

Food and water are requirements for a healthy body to survive in this world, but it's the soul that needs no human intervention to survive and death is a welcome respite for the spirit who is trapped in a broken body.

what i got from the original "check out" post was that people need to take the reigns themselves, and prepare for the possible results of your own illnesses, accidents and end of life care. not to depend on when the Dr.s think the plug should be pulled, or on how your family will be making decisions for you ruled by their emotions. people should have the correct legal documents prepared in case of these events. so your wishes are known. so all these freaks don't decide when you would want to live or die. you've already let it be known.

I on the other hand get the feeling that Lisa just felt like being the 'odd-one-out' of your overwhelming response of support.

I find it hard to believe that even a general citizen doesn't realize that situations like this happen all to often.

Humans are selfish creatures, not meant in a bad way, but it is true and in the end - we are struggling to try to survive and protect ourselves from the harsh truth of the world around us - an this can harm those we love the most.

I would suggest Lisa do a little more research on the topic before forming an opinion that makes little sense and comes across like a stroppy child that was just told that Santa Claus was a lie.

I completely agree with the last part of your comment: "The majority of us healthcare workers mourn right along with the families when tragedy strikes."

When my aunt passed away last year from stage 4 pancreatic cancer (7 weeks and 4 days from day of diagnosis until the day she died..."quick" is an understatement) in the palliative care unit in the hospital, one of the people that was just as broken up as we were was her primary nurse. She bawled her eyes out...and she was one of the ones "killing" my aunt by giving her more pain meds than healthy people were legally allowed to have.

Dear flaming Lisa, I am so tired of ignorant but opinionated people just like you. Just the thought of someday having to meet you and potentially care for your family/friends makes me heartsick and exhausted. I hope that your catholic god soon sees it fit to send you even the tiniest ounce of wisdom and compassion. ~M

Darn, I was looking for a well though out rebuttal to Dr. G. and the 100-plus validating comments. Instead, we have an ad homimen attack from a woman who is in denial, is ignorant of the facts, or both.

I especially liked the bit about not beleiving that this problem is occuring because she doesn't see it in her life.

With that rationale, I should have trouble beliving that people routinely steal and rob, maim, torture and kill each other, and that grown men rape little boys and girls with impunity. These horrors MUST be fabrications of those who work in law enforcement, because I have never ONCE seen any of the above in my own life (Thanks be to God)

Just because you don't see something doesn't mean it doesn't exist. We Americans are very good at keeping nasty realities in sealed little compartments---nursing homes, jails, mental institutions...all contain the painful truths we wish didn't exist.

Wow. Futile, extensive, expensive life "saving" care is given daily in our nation's hospitals. DAILY. If you've ever worked in acute care...it is going on all the time. All. The. Time.

I'm a hospice nurse who is also a pro-life Catholic. There simply comes a time when, for the good of the patient first and foremost, death should be allowed to occur. The body knows how to die, I see it every day. Food and water must never, NEVER, be witheld. But, once the body can no longer take in food or fluids orally must this require the invasive placing of tubes to force 'nutrition'? I say no. Death is not a violent act (excepting trauma, of course). Shoving tubes down noses or surgically placing tubes or even continuously sticking a person with needles to force IV fluids changes this. For a truly dying body, not taking food or fluids is not suffering. They do not want it, the body becomes uncomfortable when it is forced (this is supported by many studies which I won't cite here, but they can be found easily).

As the body attempts to shut down, circulation becomes compromised. This generally results in fluid backing up into the lungs, causing respiratory distress and often extreme bloating and swelling. This is NOT comfort care, it's torturous. Dehydration is not an enemy....at true end of life.

It is not a sin to die or to allow death to occur. Death is inevitable. It is wrong to cause death to occur (I would never defend Kevorkian).

Granted, one should always err on the side of saving life.....but once the writing is on the wall, let's get real and let go.

As an R.N. I agreed with everything Dr. Grumpy wrote in his original post. Flaming Lisa is an example of an uninformed family member we deal with every day. They lack the knowledge to make these important decisions.

Wow! Seriously, WOW. I feel great sympathy (maybe pity) for Flaming Lisa, reality is not part of her life. And to throw the 'Catholic' card out there is just ridiculous. I'm Catholic and caring for my Grandmother at the end of her life and giving her the dignified death of her choosing was the most spiritual, life changing event in my life. She did not want 'extraordinary measures' taken to extend her life, she was DONE, so we did the only CHRISTIAN thing we could do and let her go. (am I being inflammatory?)

Dr. Grumpy, your original post was beautifully written and made a point I have agreed with for years. I have a heart condition and every time I go under I make sure affairs and wishes are settled for this very reason, I don't want my family to have to make horribly painful decisions and I don't want some misguided, grief stricken parent, sibling, mate to have to live with their decision afterward.

(I agree with Patty, there are atrocities none of us wants to believe exist, however, those of us living in reality know they are there.)S

Doc, it's YOUR site, you do not HAVE TO "play fair." Your site, YOU make the rules.

That said, I think Gert is my new hero. She may not agree with euthanasia or Kevorikian -- and I believe that's her right on the planet -- but she's a breath of fresh air from the "pro-life Catholics" who claim that life must be preserved and extended at all cost.

The Pope declared that artificial means to create life is bad, that babies should be created naturally. I'm no religious scholar, but wouldn't that also extend to the idea that artificial life preservation is equally bad?

And to Pattie, RN: The "I don't see it so it doesn't occur" is a form of logic failure called "hasty generalization." Generally this comes of the form "Everyone I know who has done X has had Y happen, so X always causes Y." ["Everyone I know who got old and sick went to live with their children and died comfortably at home. Therefore hospice care is useless because old people can just die at home."]

My Mom and I just went through the end of life stages together. Or should I say I went as far as I could with her, she died on Feb. 7.

It was a combination of factors, 2 problems she beat in Nov., when all but one doc said she had to die from them and soon. But, they did not know how stubborn and strong she was. As the nurse advocate at the hospital said, she proved them all wrong while on a DNR.

I got her home for about 3 weeks, then it was very severe frostbite of both hands. She decided to walk her dog one MN. night when it was 20 degrees below, and she fell and it was 30+ minutes before I found her.

Then we made the hospital, sub-hospital care. Watching her have the dressiing changed on her formerly beautiful now blackened hands. She would have lost all but one thumb. She got urinary MRSA, developed delerium, was stoned to the eyeballs on meds which she hated and got gangrene.

We had the late night talks about what she should do. All I could tell her was that I'd back what ever decision she made.

She had excellent medical care during this time and care I wouldn't wish on my worst enemy. Medical personnel are not created equally. But the ones that cared were so genuine. The doc that helped her the first round agreed with me that it was time for nature to takes it's course. He hugged my shoulders in the first moment and only moment she didn't know who I was. And get this he was, horrors, a surgeon.

I watched very young CNA's at the nursing home be so kind to her it brought tears to my eyes. I watched Mom work that lone thumb into a teacup handle, so she could still be independent in one little thing. We discussed amputation, what her life would be like living forever in the nursing home. We talked about how much we loved each other.

I didn't strangle the charge nurse in the home when when I found out it had been 10 days since her last bowel movement and no one had noticed. Odd, since impactions were part of the initial cause and continued throughout. Why was it so hard to make sure an old, lady on narcotics was pooping on schedule? Especially since I emphasized this problem on admission to him. This is an 80 bed facility, should it have been a problem? To me he was obviously in over his head. Blank stares met many of my reasonable questions. I think the few questions I ever asked of him weren't that hard.

The end was heartbreaking and not pretty, in the last week as she fought to live, because it was the only thing she knew how to do.

My one blessing, that thourgh her morphine haze she was able to tell me that she was finally ready to go. And I had to let her and my heart cracked as she took the last of thousands of agonized breaths she took in the week it took to die.

Medical personel are not all good or all bad. There are angels and burnouts among them. None of them are all knowing,yet many showed wisdom and treated me as well as they did my Mom. I'm sure for many that wisdom was hard won. All were willing to state an opinion on if she could survive, some were right and some were very wrong. I only hope that the ones that helped so much heard my gratitude, which I freely expressed to them.

In the end, it was my Mom that said she was ready to go and that's what I hold onto. I'm so sorry for anyone whose loved one couldn't or wouldn't say that. I think it showed great courage and her trademark strength to say it.

Dr. Grumpy: This is probably too long and maybe too error ridden to post. I just don't know how long the grief will take, because I really haven't had a chance to grieve yet. My family is like a group of frenzied, feral ferrets over her very small estate. May there be someone to judge their actions someday.

Thank you for reading and probably understanding much of what I tried to say.

In my own case where my mother had one lung not working and the other at two-thirds capacity, with a tumor pushing hard against her brain, as well as other tumors littered throughout the rest of her body just festering away, my sister and I could have decided to have her induced into a coma so we did not have to face the reality that she was going to imminently die. The multiple doctors and nurses had done all they could to fend off the cancer but they could not. Unfortunately the science is not there yet.

My sister and I felt it would be for our own benefit that we would keep her alive because we were too weak to let her go peacefully, finally, instead of prolonging the inevitable for our own self-indulgent purposes.

Sometimes a hard decision must be made to let a loved one go and it's hard to actually do it but just like the celebration of life when there is a birth comes the reality of death.

This posting shows how important it is to have a living will. If the patient indeed did want to die, the living will spells out what type of care they will receive. It is common for a living will to contain patients wishes of antibiotic, anti-arrhythmic, dialysis and mechanical vent therapy. These wishes can't be overridden.

If there is no living will and a family member(s) have power of attorney they they can act FOR the patient but they act as they see fit and that is not necessarily the same as the patients wishes.

It seems to me that Lisa doesn't understand the difference between killing someone and stopping the fight and allowing a patient the comfort of a natural death. For all of us there will come the time to stop fighting, whether we pay attention to that message or not. Not giving antibiotics to a demented, chronically ill and suffering patient with pneumonia is not killing them, it's allowing nature to take it's course. Modern medical science has lengthened life to such an extent that some people seem to forget that death is still inevitable. And, many times, a relief.

You are completely wrong. Lisa's post has nothing to do with relgion, instead it has to do with ignorance, and I take exception to your blanket categorization of "right-wing religious people". Most Christians that I know understand that death is just a next step in our journey and are ok with that. Of course there is grief over the void left, but that is just part of the process.

The ignorance that Lisa shows is the same thing that many in this post have already stated, the ignorant belief that man can overcome death through machines, usually at the cost of increased suffering in the one they are supposedly protecting.

I'm reluctant to justify Flaming Lisa's comments, but since she decided to single me out I would like the opportunity to rebuttal, more for my benefit than her's.

In regards to the difficulty of giving antibiotics to a woman (or man) with a UTI - yes, it can be complicated considering the number of people allergic to various antibiotics. Also, Vancomycin can cause nephrotoxicity, thrombocytopenia, and possibly liver failure. Levaquin can cause liver and kidney failure. Cipro - same thing. Pattern here?

Where is my compassion? I share it with every patient I meet. Often times the most advanced care I give is holding a patient's hand and reassuring them that they are going to be okay, that I am taking care of them, and when we get to their destination, I am going to make sure that the receiving staff understand their situation and continue to take good care of them. I have countless letters from patients and families thanking me for my compassion and care.

I'm "only" a critical care paramedic and there is a lot about medicine I don't know. That being said, I have two bachelor's degrees and most of a master's I worked on before being called into emergency medicine. Idiot might be a stretch, considering the definition of an idiot is someone with the mental age below three years (answers.com).

True, UTI's do not have to be fatal - but I believe I mentioned pneumonia as a dying person's disease as it is a complication of fluid build up, immobility, decreased cardiac function, and immune system deficiency. Or simple aspiration of tube-feeding and incorrect positioning.

I didn't specify an age limit in my comments. I may or may not have ever transported a patient in their 20's - chronic vegetative state because of an anoxic brain injury secondary to a heroin overdose (generic enough for HIPPA?). These conditions have no boundaries.

Lisa is more than welcome to come to my CCU, where I have (currently) eight patients (out of twenty beds) who are undergoing every damn test imaginable, most of which are painful, because their families choose not to recognize that the end has come.

Those CCU beds that are taken up by the truly hopeless cases could be better used by people who actually have a chance at recovery. I really hope Lisa never has a family member who belongs to that second group, but who has to be diverted to another hospital because of all the DIBs at her first-choice facility.

As much as you "healthcare workers" keep harping that this happens all the time, I have a hard time believing it. I don't see hospitals crammed with people being given every possible test under the sun in these circumstances. It is an exaggeration on your part.

Lisa's above statement is what caught my attention. I get the feeling that she does not spend her work day in a hospital setting as she did not support her statement with her experiences working in the medical field.

It boils down to the fact that since it's not covered on the news and because, it's not happening.

An emotional response with no supporting facts. But then we all get emotional so I understand that aspect of her response.

Eh, just send Flaming Lisa to be the caregiver for the next neurodevastated, agonal resps, bleeding from every orifice, febrile and posturing patient with decubitus and contractures that can linger an undetermined amount of time if you keep cutting into them to find access for those precious, precious tubes. Next up I hope you'll find some commentaries worth publishing about the extraordinary efforts put forth by hospice workers attempting to give us peaceful surroundings at the end of life. I've run around in the middle of the night finding portable oxygen and suction (and just try figuring out the narcotic administration to go with it thanks to the fear of misdirected medications) to send home with a family and a hastily procured nurse so that there was the slightest chance that the ICU wasn't the last sight and sound where an imminent demise took place. Nothing about ICU is set up for a comfortable family experience of death, no matter how many Kleenexes you put in the family room, and I work hard to get the hopeless cases out into better, more family friendly surroundings. And support organizations working to improve the experience of famlies like NowILayMeDownToSleep, a service that takes professional quality photos of terminally ill children and neonates for the families to replace some of their horror of those final moments together. If you don't trust the docs, then find us an alternative Ms. Flaming.

Johanna said exactly a phrase that I've used before. Just because we CAN do it doesn't mean we SHOULD do it.

There are times that artificial means of providing food and water will interfere with the dying process. Most people in their final days don't eat or drink. It's a physiological mechanism that happens. It's just a part of the process that can be extremely hard for family members to watch. I'm thankful in my line of work for palliative care teams and hospice teams that can sometimes explain this so much better than I feel I can.

Wow. All I can say to that is she needs to (just one time) watch a person in agonizing pain dying of Cancer. I've seen it. It wasn't just at work, it was also with a family member. I wouldn't wish it on my worst enemy.

I used to work in the VA health system. We won't discuss the patients kept alive in hospital--then home for 2 days---then back again because deadbeat, useless family would lose the pension when the patient died. Pressure ulcers, contractures.....it is pitiful.

The one thing I want to add is that those who state that doctors aren't neutral are right--but families are not neutral either. We make decisions for ourselves, our loved ones, as best we can, based on what we know about the situation and the person. And we are influenced by our own hopes and fears and needs, doctors, families, anyone. It is true that sometimes things don't turn out the way we expect. We choose to have an operation because it might make things better, but sometimes we get worse instead, or complications from the operation itself are fatal. We choose comfort care for an elder with a bad stroke, expecting death, but sometimes the person, removed from the hospital setting to a more peaceful environment, gets better--maybe for a few days, maybe much longer. In either case, were we wrong, or did we simply make the best choice we could? Human beings are not perfect and medicine not an exact science. And Lisa, as others have stated, Dr. Grumpy's scenario is indeed very common. You would have the families make the decisions rather than doctors, but you seem also to want one particular church to be allowed to make decisions. Maybe that just shows how complicated these situations can be, even leaving Kevorkian and Schiavo out of it.

Wow! Perhaps communication is the word for the day! As much as doctors and nurses deal with this everyday most people do not. Rather than speak about people going through what could be the worst days of their lives with an attitude how about some compassion? Being confronted with the imminent death of a loved one can make any educated, sane person a wacked out loon. It's up to the doctors and nurses to find a way to communicate the "whole picture" to the family in a loving yet realistic way. The problem may be that with a steady steam of specialists in and out of a patient's room there might be one who offers a glimmer of hope, which a family will grab on to. People aren't selfish when they want continued care, they are just trying to do the best they can.

All I know is that when it's time for someone in my family to go, I don't hear the news from a doctor or nurse who "has seen this all before" and has my loved one's death pegged down to the minute.

A Power of Attorney and a DNR do not necessarily help. I had a friend for whom I had Power of Attorney AND she had a DNR and the stupid doctor brought her back, saying he didn't know what a Power of Attorney is. Why he ignored the DNR was never explained. This forced me to make the decision to withdraw food and water. Lisa needs to read the history of this issue in her own church. Traditionally when someone could no longer feed themselves, the church didn't demand that it be done artificially. Terry Schiavo fell under this. She shouldn't have been being kept alive by the church's own rules. (Sorry, won't capitalize it.)

About antibiotic use for dying patients; at our hospice we use antibiotics frequently. As long as a patient is experiencing quality of life (quite a subjective term but basically is able to interact with the living) and is not imminently dying we have no qualms about treating infections. Things change when a patient is declining rapidly and death is within days or hours. At this point, giving antibiotics merely prolongs dying and does very little to improve or save life.

There is no question that if a patient is experiencing pain from an infective process they will receive antibiotics. Many, if not most, end of life infections are not painful. In fact, once a body is weakened by the terminal disease (cancer, heart disease, you-name-it) infection (usually pneumonia) will take hold and allow the patient to reach the final stage of death. Pneumonia was once called "the old man's friend" because it allowed folks to die in their sleep. It still does.

I would like to tell "Flaming Lisa" To go pick up the Business Week Magazine and open up to the article "Lessons of $618,616 Death" written by a women who gave a different perspective to caring for her ailing, now deceased husband.

The article won't change her opinion, but it discusses from a loved one's point of view just how worth it is to "save someone's life" if you are only prolonging suffering and the inevitable???

Tracy, you're right. I remember a patient with an anoxic brain injury; after a new EEG I asked the neurologist on the floor how things looked. "About as bad as you'd expect," said the neurologist, frowning. The family, though, heard the same neurologist say there was a 5% chance of some recovery, and of course they took that--they were not in any sense ready to give up the fight, and they said, quite accurately, "5% is not zero."

Moving on--I also think sometimes the family feels as if they are given 2 choices: full speed ahead or nothing. I know the docs where I work do their best to be clear about choices but we all know that in a crisis situation we can't process everything said to us. Families sometimes feel as if their doctors have given up on their loved ones with no warning, and that feeling can be exacerbated by the hospitalist system, where a family just begins to remember one doctor's name when the care is taken over by someone else, who may see things very differently. Many families have said, upon a loved one's admission to hospice, "Yesterday they were talking about him going home and today there was a different doctor who said we needed hospice. I don't understand." Luckily our hospice physicians can and do take the time with families to get the information they may need, and if in fact the patient doesn't belong in hospice or gets better or the patient or family decides in favor of more aggressive treatment we rejoice with them at the hope and facilitate their getting where they want to be.

Nothing, but nothing about this is simple, and I think more talking about it is terrific, so thanks to Dr. Grumpy!

Debates like this are one reason why I have chosen to execute an Advance Healthcare Directive ("Living Will") despite being only in my twenties. I have no desire to "live" as a sickening parody of a human being on the account of a well-intentioned (or guilt-stricken) friend or relative deluding themselves about my quality of life or prospects of recovery.

I wholeheartedly encourage others to put their wishes concerning end-of-life matters in writing and discuss them with their family, whatever they may be.

"We Americans are very good at keeping nasty realities in sealed little compartments---nursing homes, jails, mental institutions...all contain the painful truths we wish didn't exist." [Pattie RN] While this may or may not particularly pertain to Lisa's ignorance (she may be too young to have experienced life, or placed in situations where she cannot form her own opinion, or in too close proximity to death--denial, and not coming to grips), the statement seems particularly apt to the general non-health care provider public in understanding health, life, and death.

Most comments here are from medical profession where we ascribe to sacred oaths about our duty and the sanctity of life.

One might surmise if Lisa was inoculated against depersonalizing human suffering as observed day-in day-out by healthcare workers for those tucked away in society’s little compartments, there might be a more realistic opinion about futile hopes in miraculous cures and more a tendency to accept that there is a time to every season.

Perhaps, Lisa is confusing not withholding life-giving treatments with resumption of a degree or capacity of quality of life issues. One might think if she retained this attitude as a health care professional, fellow care-takers might be somewhat leery of working with her in making so-called 'life and death decisions'! Maybe not on par with Dr. Mengele. But, if I attended a Code I'd sure be asking for miraculous divine intervention for quick passage, if after a number of cracked ribs, she refused to call it.)

I, too, am Catholic, but find it unconscionable to traipse from hospital to hospital in search of a cure with a dying body.

Hmmmm. It's too bad that Flaming Lisa's Post had to be all balled up with religious mumbo jumbo and lack of knowledge.

As a recovering Catholic, I believe that dignity and comfort are considered an ordinary (required) part of care--so Terri Schiavo should have been allowed to die much sooner, and save her some small shred of dignity, and ease her suffering. No one should be forced to persist in a vegetative state, and I think it is imperative that everyone comes up with a plan for what they would wish done, should their voices be taken from them, leaving them unable to speak on as their own advocate in their own healthcare.

Kevorkian is a man, who offered people something that this country is unable to accept. Sometimes, death is the only way to end suffering.

Flaming Lisa has obviously never dealt with the awful indignities forced upon a patient, who's family refuses to accept that they are dead. Has never watched as a patient codes five times in a two hour time frame, as their body keeps shutting down, and the family insists on the hospital doing everything in their power to bring that poor soul back. She has never had to deal with a person, who's extremities have been turned black and lifeless by seemingly endless norepinephrine drips.

Flaming Lisa: Is it really so hard to accept that medical professionals might possibly know what to do in a medical situation? Where do you get off calling someone an idiot? Obviously I am too far-removed from my catholic roots to remember the part of the bible where Jesus said "Call those with opposing viewpoints idiots."

We have not lost our hearts. While I can not speak for everyone, I can say that my heart is as warm today as it has ever been. That said, it kills me to watch the indignities that families put their loved ones through because they refuse to let go. Thank you for clearing up why I distrust people who have never worked in the medical profession, and have never had to see the things we've seen.

@terri c: "The family, though, heard the same neurologist say there was a 5% chance of some recovery, and of course they took that...and they said, quite accurately, '5% is not zero.'"

The chance of recovery to an acceptable level of function is most likely zero percent. So the issue is not "will the patient recover" but "if the patient recovers, to what extent?" and "is this course of action consistent with his/her wishes?"

I've watched the ethicist and palliative team in our hospital have this talk with family many times, and often, communicating the big picture requires stressing this more than anything else. Most of the doctors I've met are very good at having this conversation.

Flaming Lisa said "As a Catholic, food and water are considered ordinary (required) care even if medically assisted--so Terri Schiavo would be alive and her murder would never have happened and perhaps her parents would have been able to care for her as they wished. Wow! How awful is that????"

Being Catholic as well, I feel that there needs some clarification here. The Catholic Church teaches that there is no requirement to go to extraodinary measures. Extraordinary measures are anything above food and water by mouth. If a person cannot swallow, say after a stroke, it is not mandatory to insert a feeding tube. You can put one in if you feel that is what the person wanted, but there is no "MUST DO THIS". A surgically inserted feeding tube does qualify as an extraordinary measure.

And I would like to tell you that it does happen all the time. My very first patient out of nursing school had a feeding tube, a tracheotomy, an IV, a foley catheter and a rectal tube. She also had a big hole in her armpit where they removed one of her lungs due to cancer. She had a cardiac arrest during that procedure so they left the hole open to be packed twice a day when she was sent home. Her trach had caused her esophagus to ulcer. In 15 years, I have seen too many of these disasters. I have never worked in ICU, but every unit I have ever worked had a couple of patients that their bodies were still alive, but the soul was screaming to be let free. Letting this happen to anyone is a sin. Doing this to your own family? Not in my book.

Comfort measures include pain and symptom control, family at the bedside (not fighting) and a gentle touch.

My dad is 76. He remains in good health, but I know that at some point I will need to be ready to let him go. He has made it clear that he does not want any tubes. He does not want CPR. He might take antibiotics if he gets pneumonia, but if they don't work and he slips into a coma, I'm not going to have him vented and resusitated. I will get a priest to him if I have to go down to the Church and drag said priest out of bed if I have to, but I will not extend his time here because I'm not ready to let him go. I won't speed up the process either by giving him unreasonable amounts of morphine, but I will do my utmost to give him all the dignity that is in my power to provide.

Oh, Dr. G....I am so grateful to you and your followers (Flaming Lisa excepted). First your writing on this subject was inspired and beautiful.Second, I am reassured and delighted that almost all of your vast audience agreed with you (amd me) so eloquently. Sometimes I despair that there are none but idiots like Lisa in the world....you and your readers have given me hope.

"just because we can doesn't always mean we should" from Joanna is the best comment here.

and, I simply wanted to say that the biases should stop. I am a proud Catholic and pharmacist and I would never agree with taking a dying woman to multiple hospitals and doctors to try to get a different answer when it was clear from the start what the real answer was. all people have their own shades of belief and you're wrong to lump everyone together for any reason.

About Terri Schiavo; during that whole episode virtually everyone with whom I spoke (except for my fellow hospice nurses) about her case began by saying "well, I wouldn't want to live like that but....." But what? You wouldn't want to live like she had to, but SHE should be made to? Come on. Sunshine RN is right, food and water by mouth is reasonable, but feeding tubes are extraordinary.

I also find the Catholic card inappropriate. On the original post, I commented about my mother in law in the end stages of her brain tumor chose not to have a feeding tube because she did not want to be a science experiment. I also mentioned she was an RN. What I didn't mention was she was an extremely devout Catholic who spent the majority of her professional life caring for retired priests in a nursing home.She could never forget the images of her end stage patients curled into fetal positions from lack of movement whose only connection to life was the feeding tubes keeping them alive. Would she remove it herself? No, because her job was to care for the person and inserting the tube wasn't her decision. However, there was no way she was going to permit herself to turn into a dying shell without hope. She had seen it over and over again. In all seriousness, I think that scared her more than dying of the brain tumor.

I feel so lucky to be a veterinarian. I can ease the suffering of any of my patients when their owners feel it is the time. There are many cases that I wish I could have done more tests to get the *answer* but that I didn't do because it would not benefit the pet or change the outcome.

This past week, I had a patient that had multiple tumors in the abdomen. He started seizuring. I was pretty sure there was a brain tumor. Did I offer a CT scan? I mentioned it, but more than anything, I advised the owners that surgery to remove the masses in the abdomen or a CT scan would be useless.

I have had brain dead animals come in after being hit by a car....owners want me to do "everything" even when there is no hope.

This week, our hospital has had more than its fair share of death, ranging from an aggressive animal that was euthanized so it could not harm a child to an immune compromised cat with a horrible infection to the several cancer patients in the last few days.

A few months ago, I was euthanizing a dog that the woman claimed was 25 years old. It was skin and bones with bed sores, hind end caked in diarrhea. All of the muscles on his head were sunken in and you could barely see the eyes for the goop. As I gave the injection of euthanasia solution, I petted him and we all told him what a great dog he was. Then the owner turns to me and says, "You must really hate dogs to be able to do that."

Talk about ignorance. Since she was dealing with her dog's death, I didn't drop any science on her. I said that death is a gift when life has become to painful to live. Of course, I was not the one that watched this beloved dog, chained to a post outside, dying slowly over who knows how long before finally bringing it in at 3 AM on a Sunday.

Personally, I believe in assisted suicide. If that is what the patient wants, and the situation is such that they are only going to experience more pain, it should be offered.

There's a reason why I can't take people like "Flaming Lisa" seriously. I could barely continue reading after the second sentence started something like this, "Terri Schiavo would be alive and her murder would never have happened".

Seriously? Murder? Certainly NOT. It's distressing when 'removing a feeding tube' is equated to 'murder'. Then we don't end up talking about the same subject and we start talking AROUND each other.

Words matter. Drivel and hyperbole spewed forth from self-righteous right-wing zealots always turns me off. I was 17 when the Terri Schiavo incident happened. I agreed with the husband then, and I agree with him now (it was a PRIVATE issue). But then again I'm Canadian, which, for some, means that I'm an evil socialist.

Could Lisa perhaps let us know what her occupation is? Everybody has been thrashing her (and I don't agree with her!!) but it might give others some insight into her way of thinking. This whole debate has been very interesting, but obviously rather one-sided. Dr Grumpy, I think you are on your way to your 2nd 100 record response hit! You certainly struck a sensitive chord. Keep it up! You make my day, every day, especially when my patients (mostly severe, chronic pain) / practice become a bit overwhelming.

I have not read all the posts but from her original post and Grumpy's. Thank-you both. I have been on this table before. With a DNR, I would not be here. I was gone after a routine surgery. Because there was an angel on my shoulder according to the charge nurse, I lived to breathe another day.My family went through hell for 3 days wondering if I would "make it" and if they would have to make "the decision" I swore I would not do that to them again. And they will not. Until tonight I was DNR all the way, call the funeral home and order flowers. Even though I might be saved a second time see above about family. My living will soon state. Take extraordianary measures,IF, after 48 hours there is no sign of improvement or hope for a postive outcome. PULL THE PLUG. My family does not have to decide, wil not wonder what if with my previous history and I will not be left to languish and be a burden on my family or the helath care system.

doc, this resonates with me b/c i just found out i had metastatic cancer. i've calmed down since my news, and this discussion on your blog has convinced me to update all of my end of life documents - though i expect to fight this for quite a long time.

Many folks have been calling Lisa various names. I think her opinions are ignorant - but I also think they stem from a lot of fear.

When I got my news, my first thought was that no matter what, I wanted to live as long as possible - NO MATTER WHAT.

Now i've gone thru the death of my mom in hospice, and my dad in a nursing home. I know the drill and each of them went peacefully without inducements to stay after they were ready to go. I've seen friends allowed to die when they were ready to go. Nonetheless, when i heard MY news, i was briefly Lisa.

My point? Have a little pity for her fear. There is a lack of experience in death that underlies her writing. Even with 'experience' in death, it's very easy to understand the dubious attraction of 'do everything to save me/my parent/my spouse/my friend.

"As much as you "healthcare workers" keep harping that this happens all the time, I have a hard time believing it. I don't see hospitals crammed with people being given every possible test under the sun in these circumstances. It is an exaggeration on your part."

This is the part that kills me. She clearly is completely removed from the situation and yet asserts her authority by telling us that we are exaggerating and lying. I really wish she could just come on a few ICU rounds and see how it's done, day in and day out.

For the Canadian who imagines him or herself to be an "evil socialist." The difference between your health care system and ours is that we still have to make these choices. In Canada or let's say Great Britain, the choice would be made for you by the gov't. Americans don't think Canadians themselves are socialist but this American thinks their health care system leaves much to be desired. Especially after working for a surgeon for a number of years who did operations at least omce a week on people who were denied care (because of age or health) in their own countries.

I think Lisa has never had to stand by helplessly and watch a patient suffer for months on end while the family refuses to stop the madness. Often, it's for a multitude of reasons: guilt, denial or the worst I've seen is that so the family member who makes the decisions can continue to "get her check" for a few more months.

speaking as a canadian... I gotta point out that the "socialist" label is often misused in regards to the real way in which our healthcare system works... each province has a slightly different way of governing it's individaul healthcare system, and certain test/ procedures are quicker to recieve and certain medications/treatments are more frequently prescribed in some provinces than others depending on wether you are required to pay an additional provincial annual healthcare premium or just the standard federal/provincial tax, but regardless of your province, once you are undergoing hospital care the government does not have the power to "pull the plug." That is a decision left up to a the doctors and the family, if there is a disagreement, just like in the states, the issue usually winds up in the courts and the media.

To Tracy specifically- what people generaly do, if they are unable to to attain a procedure or surgery in one province, in an adequate time frame for their liking, is simply move to a province with a higher premium...it may not be a perfect system...but i's say it beat's a country full of people who can't afford to get a basic x-ray or a symple lab test for strep-throat

I just want to say thanks to both the human doctors and the animal ones. I for one, see Flaming Lisa as panicked. Who knows what she's going through right now? The vet's post reminded me that I once had been to my beloved dog, what Dr Grumpy's patient's family was. It took a vet to ask me gently, "Why are you doing this? Can't you see your little dog is suffering?" Until that moment, I had thought I was going to find a miracle cure when there was none. And bless the Vet who could inject him and end his suffering.

I'm Catholic. Yet I often think we should have the same option as animals - the right to end our suffering.

I actually feel sorry for Flaming Lisa. I'm not in the medical profession, but I've watched several people die and luckily for them, their family members had the sense and the backbone to do the right thing. To pull the feeding tube and let the brain dead woman die. To up the morphine on my 95 year old mother in law, so she could go pain-free, not feeling the stomach cancer that had eaten up her inside.

My brother in law died at 52 from a brain tumor. It wasn't pretty, but he had a DNR and living will.

I think the point that Lisa is missing is that at some point we all have to say goodbye. Sometimes when we are in the middle of a heartbreaking situation, we need a voice of reason to definitively tell us what we refuse to believe. Dr. Grumpy wasn't suggesting that the board of doctors make the decision to pull the plug, but rather they make a decision as to whether insurance should pay to prolong the inevitable. If her husband chose to continue seeking treatment, it would be on his own dime. As much as we all would love to believe that every health care resource will be expended to prolong our lives, it's completely unrealistic. Health care resources are limited, in the same way our natural resources are. We have to use them wisely and efficiently. I personally would rather my insurance premiums go toward vaccinating children (one of the best health care investments out there!) with the outlandish amount of money being spent to torture a poor woman who is long gone. We have limited resources, and it's time America woke up and realized it.

Lisa-- you are going to die. Me, Grumpy, all the health care workers who are smarter than you-- we are all going to die. The difference is, I will not bankruupt my family to give me another ten days or ten months of meaningless life. Moron.

Killer Kevorkian (catchy, I'll grant you that): we now have legal physician assisted suicide in the states of Oregon, Washington, and Montana. KK was merely ahead of his time.

Terri Schiavo: aw, fer chris'sakes! per http://www.religioustolerance.org/schiavo6.htm:"Courts and doctors appointed by the courts ruled that she was in a persistent vegetative state....Unlike patients in a coma, patients in a persistent vegetative state can never recover.Medical Assessment: Leon Prockop, a professor of neurology at the University of Southern Florida, has studied Terri's CAT scans. He believes that Terri's life effectively ceased FIFTEEN YEARS AGO...."Her death occurred some time ago....That brain tissue cannot come back. It never has, and it never will." His view "coincides with the vast preponderance of expert medical opinion...""

What, did Schiavo's parents think year number sixteen would be her lucky year? Given her medical condition, if Schiavo's parents couldn't bear to live without her, they should have taken her to a taxidermist and had her stuffed so they could always have her around (yeah, I know that's extremely harsh, but, God-damn it! Brain-dead for 15 years? Time to let go!!! The magic Jewish zombie was not going to be performing any miracles for her). Murder, my ass!

Flaming Lisa:"You've all lost your heart!" Yeah, and you've obviously lost your freaking brain and the ability to "get the point."

With all the legal documents available today, there is no reason your life should end (or not end) in a fashion NOT of your choosing...you just have to take the time to fill out the paperwork.

My entire family has filled out the documents, and further, we have all discussed with each other how we want our end of life to go. And I know that if one of us should find ourselves in a lingering end of life situation, our wishes will be honored and carried out.

p.s. to KateA - God bless you and all other compassionate vets who humanely end the irreparable lives of our furry friends.

I'm a little late in the game, but I wanted to comment. I also am a pro-life Catholic, and I want to make it clear that extending life at all costs is NOT a mandated part of the Catholic faith. Look up the Catholic directives for End of Life care (specifically nos. 56-58, I believe) to see it written out plainly. When we were expecting my son (born with a severe heart defect,) we went to see our priest about whether the Church supported the decision I was leaning toward, to allow our son to pass away soon after birth. He consulted a priest colleague, who affirmed that yes, such a decision is both in alignment with our faith and is done routinely. Lisa has taken "pro-life" to an extreme and unreasonable level. God created our son perfectly, defects and all. I struggle with guilt daily that I may have said "NO" to God when he asked me to do the most difficult thing ever, to give my child back to Him.

ps - Lest you think I'm some heartless monster, God has blessed us over and over through our son, and we love him very much.

It is also not Christian, spritually sound, or morally justified to somehow convince yourself that not actually having any chance of living, and having your body kept alive because your family members are all too sefish to see past their own fear of death isn't toruture. Just ridiculous...but thanks for the interesting post Dr. G.

So, I will confess I haven't read all 73 comments. I read the 13 that were there the other day when I first read this post and then thought about it off and on.

I see both sides, and what about this?

It seems the problem arises when the patient (and family, but hopefully we can focus on the patient) has a belief system that is different from his/her doctors' belief system. Either, they believe more strongly or believe in something different. So, couldn't we have a "death panel" that is composed of the medical folk PLUS a religious representative...priest, rabbi, elder, whatever? That person can weigh in on the religious side and somehow...come to a consensus?

The problem with your solution Banshee is that this sort of situation occurs every day, in every hospital, over and over (just not always to the point of getting the press or attorneys involved). If we needed to consult a "panel" every time we discussed any issue that could be considered futile care, we'd all be in meetings all day. Most hospitals already have committees like you suggest, but only for the cases that have already gone too far. The problem is that the public has an inaccurate perception of medicine. You watch TV shows where 99% of CPR victims survive without any loss of function. Reality? 99% don't survive or are severely impaired, especially out of hospital arrests.People feel guilty that they didn't want "everything done" but don't understand that "everything" can include modalities that have no hope for meaningful success and could prolong suffering (ie torture).I had a patient in the past with widely metastatic prostate cancer (to the bones which causes severe pain), end-stage emphysema (such that every breath was a struggle), and severe Alzheimer's disease (he didn't even understand from day to day why he couldn't breath and was constantly hurting), who came in with pneumonia. The one family member, who had not seen or cared for him in years, kept saying "do everything, put him on a respirator..." To what end? None of his underlying conditions would miraculously disappear. What good would meeting with a Panel of Priests do?Bottom line, I'm with you on this one Dr. G.

If Terry Schiavo were "alive" today, she'd be lying in bed staring at nothing, most likely being turned every two hours, a little wet sponge stuck in her mouth to keep it moist every two hours, having stool washed off of her with diaper cream applied immediately after, being propped up in a chair every day, with drool suctioned out of her mouth/wiped off her face, and on and on. Is that the kind of life Flaming would accept for herself? I bet not. (That poor woman's parents were nutcases, BTW).

Really, really late in the game. I'm a pro-life Catholic. I'm also in medicine. On the feeding tubes for Terri Shivo (sp?) I was taught that the reason it was murder was because she had been alive and it was withdrawn. If it hadn't been initiated in the first place, it wouldn't have been wrong. So basically, you don't have to START extraordinary feeding, but once you do, it is wrong to take it away.

Wow. thanks so my Katharine for calling all religious people idiots. Really, I appreciate that greatly. The point of faith is not that you follow your religion blindly, but that you understand your religion fully and decide whether or not it's for you. If you disagree, that particular faith system isn't going to work for you, so pick another. And for the record, JP2 had a DNR and ended up dying of a UTI. He also was a big advocate for end-of-life mercy in not prolonging life without hope of recovery. It's not the religion that says we need to prolong life, it's the emotions.

In any case, while I believe that feeding someone is not an "extraordinary measure" seeing as it's a basic human need for everyday life, I do agree with Dr. Grumpy that the end of life should not be prolonged. I've worked in the ICU, the geriatrics unit, and I've had to watch people let their child die in front of them. I understand that families get incredibly emotional, and that doctors seem cold when we tell them that the life is gone. But isn't this a problem on both ends? Shouldn't we, as the health care providers, have these discussions before patients get to this stage? Or maybe figure out how to communicate with this particular family without letting emotions get the better of either side? I've seen this scenario over and over again, but the families that really listen are those whose doctors talk to them like human beings who are suffering, not like cold-hearted torturers.

Welcome to my whining!

This blog is entirely for entertainment purposes. All posts about patients may be fictional, or be my experience, or were submitted by a reader, or any combination of the above. Factual statements may or may not be accurate.

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